Form 19 - Employer'S Report Of Employee'S Injury Or Occupational Disease To The Industrial Commission - North Carolina Industrial Commission Page 2
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2IMPORTANT INFORMATION FOR EMPLOYER
Employer must furnish a copy of this form, as completed, to the employee or the employee’s representative when submitted
to the Insurance Carrier or Claims Administrator for transmission to the Commission. Every question must be answered. This
Form 19 must be transmitted to the Commission through your insurance carrier/claims administrator, and is required by law
to be filed within 5 days after knowledge of accident. Employer must also give employee a blank Form 18.
IMPORTANT INFORMATION FOR EMPLOYEE
Reporting an Injury
If you do not agree with the description or time of the accident given on this form, you should make a written report of injury
to the employer within thirty (30) days of the injury.
Making A Claim
To be sure you have filed a claim, complete a Form 18, Notice of Accident, within two years of the date of the injury and
send a copy to the Industrial Commission and to your employer. The employer is required by law to file this Form 19, but the
filing of the Form 19 does not satisfy the employee’s obligation to file a claim. The employee must file a Form 18 even though
the employer may be paying compensation without an agreement, or the Commission may have opened a file on this claim. A
claim may also be made by a letter describing the date and nature of the injury or occupational disease. This letter must be
signed and sent to the Industrial Commission and to your employer.
FOR ASSISTANCE OR TO OBTAIN A FORM 18 FROM THE INDUSTRIAL COMMISSION, YOU MAY CALL (800) 688-8349
USE YOUR I.C. FILE NUMBER (IF KNOWN) OR SOCIAL SECURITY NUMBER ON
ALL FUTURE CORRESPONDENCE WITH THE COMMISSION
[SPANISH TRANSLATION]
INFORMACIÓN IMPORTANTE PARA LOS EMPLEADOS
Reporte de una Lesión (Reporting an Injury)
Si usted no está de acuerdo con la descripción o la hora del accidente que aparece en el formulario, debe hacer un reporte
de la lesión por escrito y dárselo a su empleador dentro de un período de treinta (30) días a partir de la fecha de la lesión.
Cómo Presentar una Reclamación (Making a Claim)
Para ceriorarse de que ha presentado una reclamación, complete el Formulario 18 Notificación de Accidente dentro de un
período de dos años a partir de la fecha de la lesión y envíe una copia a la Comisión Industrial y una copia a su empleador. Por
ley, el empleador debe presentar el Formulario 19, sin embargo, el presentar el Formulario 19 no cumple con la obligación que
tiene el empleado de presentar una reclamación. El empleado debe presentar el Formulario 18 aunque el empleador esté
pagando compensación sin tener un acuerdo o si la Comisión ha creado un expediente con respecto a esta reclamación.
También se puede presentar una reclamación por medio de una carta explicando la fecha y la naturaleza de la lesión o la
enfermedad ocupacional. Esta carta se debe firmar y enviar a la Comisión Industrial así como al empleador.
PARA RECIBIR ASISTENCIA O PARA OBTENER EL FORMULARIO 18 DE LA COMISIÓN INDUSTRIAL, USTED
PUEDE HABLAR AL (800) 688-8349
EN TODA LA CORRESPONDENCIA QUE ENVÍE A LA COMISIÓN INDUSTRIAL POR FAVOR ESCRIBA
EL NÚMERO DE CASO DESIGNADO POR LA COMISIÓN [I.C. FILE NUMBER] (SI LO SABE)
O SU NÚMERO DE SEGURO SOCIAL.
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